Lossless account compression for health care patient benefits eligibility research system and methods

ABSTRACT

A system and method for determining eligibility for reimbursement for medical claims for patients may be implemented with computer software which compares a service provider&#39;s patient information against a benefit provider&#39;s database of covered persons to determine if the patient is eligible for benefits. The service provider records may be compressed by grouping all of the medical claims relating to a particular patient into one cluster represented by a composite medical claim, which may be used to query the benefit provider databases to determine if the patient is recognized. If the patient is recognized, every record within the cluster may be checked against the benefit provider&#39;s database to determine whether one or more patient medical claims are eligible for reimbursement.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent application Ser. No. 11/098,295 filed Apr. 4, 2005, which claims the benefit of U.S. Provisional Patent Application No. 60/654,028 filed Feb. 17, 2005.

FIELD

This application relates generally to data processing software for inquiring and determining eligibility for reimbursement for medical claims for patients by comparing the patient information of a service provider against a benefit provider's database of covered persons to determine if the patient is eligible for benefits and, if so, associating the patient record with the matching record in the benefit provider's database so the service provider can seek to be reimbursed for the health care services provided to the patient.

BACKGROUND

The provision of health care services in the United States has become the focus of much attention. With the costs of medical malpractice insurance spiraling, and the payments being made to health care providers from benefit providers, including private and government insurers, being reduced continually, health care providers are finding it necessary to get payments for all the services they actually render.

Unfortunately, many health care providers are not receiving compensation for the services they render. This could be due to a number of factors, such as patients not having the ability to pay for the services, and/or not having any medical payment system or insurance. In other instances, medical care service providers submit a request to determine if a patient is eligible for coverage under a private or government insurance plan, but are told the patient is not eligible for coverage. Often, payment for services rendered is denied due to incorrect data entry about a patient and/or the service rendered, through failure to associate the information with the correct patient record in the benefit provider's database, or other misunderstandings or mis-associations.

For medical care service providers, being denied payment for services rendered is problematic, and can, in some cases, mean the difference between profitability and a business that does not show a profit. Typically, such medical claims which are classified as not eligible for reimbursement are written off as bad debt for which collection cannot be achieved. Ultimately, these costs are either passed along to other patients by means of cost increases, or the care provided is cut back to save or reduce costs.

Accordingly, a continuing search has been directed to the development of methods which can help medical care service providers maximize identification of patients who are eligible for private or government medical insurance so the service providers can be reimbursed for medical claims.

Therefore, what is needed is a system and method for helping to efficiently identify medical claims for which the patients are eligible for health care benefits, which can be paid to the health care provider.

SUMMARY

Normally, claims for medical care are submitted to a patient's benefit provider for payment. Prior to submitting the medical claim, the health care provider will need to make an eligibility inquiry to determine whether the person for whom the service was provided is eligible for benefits; if not, payment to the health care provider will be denied. In many cases, the denial is because the information entered on the medical claim submitted to the benefit provider by the service provider cannot be correlated with the information in the benefit provider's database because the patient could not be located in the benefit provider's database due to inconsistencies. In some instances, this is due to a data entry error on the part of the service provider, benefit provider, or both. In other instances, the patient may not be eligible for insurance coverage at the time the services are rendered, or when the eligibility verification inquiry is made.

While software already exists that will make an eligibility inquiry to determine eligibility, and inquire as to correlation between records, there has been only partial success with prior attempts of automated eligibility verification inquiries. The existing software has only limited functionality and is not always effective or accurate. It will typically only search for records in which the patient's name, social security number and date of birth match a record in the benefit provider's database, and it returns a list indicating only those patients for which an exact match has been found. It will not provide information as to numerous other issues that are related to eligibility, such as whether the service rendered is one paid for by the benefit provider. Additionally, manual examination is typically not practical or cost-effective, given the volume of patient medical claims and records. Also, some benefit provider systems and databases may not be robust enough to handle the volume of eligibility inquiries being sent, and the submission of a large number of medical claims can greatly increase the response time.

The system and method disclosed herein may be implemented in a software program that will automatically, upon request, query benefit provider databases with a variety of different queries to find persons who are eligible to receive benefits, and who match patients in a service provider's database for whom services have been or may be provided. The software may also automatically segregate those records for which there is a match between the databases for further processing, and it may indicate the matching information found in the benefit provider's database. For example, the software may inquire whether the patient is covered by the benefit plan, whether the services provided are covered by the benefit plan, and/or whether the provider is authorized to provide services for persons covered by that benefit plan.

The software described herein may also provide a means for comparing records in the benefit provider's database against a service provider's medical claims and finding records that, while not a complete match, have a predefined number of parameters that match, such that upon further analysis and correction, it may be determined that a patient medical claim is eligible for reimbursement and can be submitted to the benefit provider, and the service provider will be reimbursed for the services performed. The software may easily reveal the field or fields in which there is a difference in the information between the service provider's medical claim and the benefit provider's database, making correction of any claim errors much simpler and making the present system and method much more cost-effective than previous systems and methods, which generally did not reveal any such partial matches, or show errors that had caused a medical claim that was submitted to have been rejected, but only verified whether or not there was a complete match.

The software described herein may also compress service provider records by, for example, grouping all of the medical claims relating to a particular patient into one cluster represented by a composite medical claim containing all of the relevant search parameters. The software may then query benefit provider databases with a variety of different queries using this composite medical claim to determine if the benefit provider's database recognizes the patient. If the patient is recognized, the software may then run every record within the cluster against the database to determine whether a patient medical claim is eligible for reimbursement and can be submitted to the benefit provider for payment. In situations where a significant percentage of accounts come from repeat visits by a patient to a service provider and where the normal match rate against the benefit provider's database is small, this account compression can result in a significantly reduced transaction load on the benefit provider's database. This process is lossless in that no eligibilities that would have been found by querying the benefit provider's database using each individual record are missed or lost by querying the database using the composite medical claim. The software allows more accounts to be run against the benefit provider's database without increasing the strain on the benefit provider's system.

The software described herein may also show whether the patient was qualified to be covered by a benefit plan at the time the services were rendered. In some instances, the patient may not be eligible for coverage at the time the initial inquiry is made, but may become eligible for coverage at a later time, and the coverage may be retroactive back to a period including the time at which the service provider rendered treatment. If this retroactive eligibility is discovered and identified in a timely manner, a request for retroactive reimbursement can be made in some cases.

In other cases, even if the eligibility qualification is not discovered in time to seek reimbursement, the un-reimbursed medical claims can be important for a health care service provider in determining if it is entitled to reimbursement under various government programs for treating uninsured persons, and to help the service provider keep accurate track of how much of such funding they might be entitled to.

The present system and method may also be used to generate reports in a variety of configurations, such as to record matches found, to assist in identifying errors, determining sources of errors, and taking steps to prevent similar future errors. A surprising number of matches between service provider medical claims and benefit provider databases of persons eligible for reimbursement were found using embodiments of the software described herein that were not found using prior art software. Even when the software described herein is used to query the same benefit provider's database for the same health care provider's medical claims, matches are found that were not found when the same or similar queries were previously made. These matches have resulted in tens of millions of dollars of reimbursements for service providers that would have otherwise gone unpaid.

The foregoing summary has outlined rather broadly some of the features of the system and method described herein in order that the detailed description that follows may be better understood. Additional features will be described hereinafter. It should be appreciated by those skilled in the art that the concepts and the specific embodiments disclosed herein may be readily utilized as a basis for modifying or designing other structures for carrying out the same or similar purposes. It should also be realized by those skilled in the art that such equivalent constructions do not depart from the spirit and scope of the invention as set forth in the appended patent claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a high-level conceptual block diagram illustrating an embodiment of the system described herein.

FIG. 1B is a detailed block diagram showing the querying of the benefit provider database, including comparison of service provider file records against the benefit provider's database, and generation of one or more files containing service provider's records and matching records from the benefit provider database.

FIGS. 2A, 2B, and 2C show samples of some of the types of reports that can be generated from the file containing service provider medical claims for which there is a matching record in the benefit provider's database.

DETAILED DESCRIPTION

As used herein, the following terms should be understood to have the indicated meanings:

When an item is introduced by “a” or “an,” it should be understood to mean one or more of that item.

“Benefit provider” means an individual or entity that is obligated to provide payments for the benefit of specified patients for specified health care services.

“Cluster” means a group of medical claims all relating to the same patient.

“Composite medical claim” means a collection of data representative of all the medical claims within a cluster.

“Comprises” means includes but is not limited to.

“Comprising” means including but not limited to.

“Constituent medical claim” means a medical claim within a cluster.

“Database” means a collection of data embodied in at least one computer readable medium and organized in a suitable way to permit a computer to select one or more desired portions of such data.

“Eligibility inquiry” means a query as to whether a medical claim is subject to an obligation of payment by a benefit provider.

“Having” means including but not limited to.

“Health care services” means any services that are rendered to address the health of a patient. Health care services may include but are not limited to diagnostic, therapeutic, preventative, and maintenance services related to the physical or mental health of a patient.

“Medical claim” means a collection of data relating to one or more instances of the provision of health care services to a patient by a service provider.

“Query” means a request for information from a database.

“Recognized” means, in connection with a patient and a benefit provider's database, that such benefit provider's database contains data representative of such patient.

“Service provider” means an individual or entity that provides health care services to patients.

In the discussion of the figures, the same reference numerals will be used throughout to refer to the same or similar components. In the interest of conciseness, various other components known in the art, such as computer processing equipment, and the like necessary for the operation of the software, have not been shown or discussed.

In the following discussion, numerous specific details are set forth to provide a thorough understanding of the system and method described herein. However, it will be obvious to those skilled in the art that the system and method may be practiced without such specific details. In other instances, well known elements have been illustrated in schematic or block diagram form in order not to obscure the disclosure in unnecessary detail. Additionally, for the most part, details concerning timing considerations and the like have been omitted inasmuch as such details are not considered necessary to obtain a complete understanding of the system and method, and are considered to be within the skills of persons of ordinary skill in the relevant art.

It is noted that, unless indicated otherwise, all functions described herein may be performed by a processor such as a computer or electronic data processor in accordance with code such as computer program code, software, or integrated circuits that are coded or configured to perform such functions. Additionally, it is noted that the software described herein may be used at a computer remote from the benefit provider's computer system and from the service provider's computer system, or locally to either of those computer systems.

A. Improved System

Referring to FIG. 1A of the drawings, the reference numeral 1 generally designates an improved eligibility verification inquiry system. The inquiry system 1 comprises unpaid medical claims 100, software 10, benefit provider's database 500, files of matches 400, and reports 450 from the files of matches 400.

Normally, medical claims 100 for medical care services are paid for by a patient directly, or submitted to a patient's benefit provider for payment, such as a private health insurance company, or government-subsidized health care insurance, such as Medicare, Medicaid or other government-funded programs. After processing to verify such things as whether the person for whom the service was provided is covered by the benefit provider, whether the services provided are covered by the benefit plan, whether the services were rendered during a period the patient was covered by the benefit provider, and whether the service provider is authorized to provide services for persons covered by that benefit plan, the benefit provider will pay the health care service provider for the service provided at a specified rate. However, if any of the numerous requirements are not met, the medical claim of the health care service provider is not submitted or processed for payment. When such a query for eligibility status is rejected, the health care service provider can seek to recover the fees due from the patient, or from a patient's secondary benefit provider, if any exists. Often, when all other recourse has been exhausted, the service provider must absorb the loss and not receive payment for the services provided.

Denial of eligibility for treatment is typically because the service provider is not authorized to provide service for persons covered by a specific benefit plan, the service provided is not covered by the benefit plan of the patient, the date on which the service was provided was not a covered date, or the patient is not covered by the benefit plan. In many cases, the denial is because the information entered on the medical claim submitted to the benefit provider by the service provider cannot be correlated with the information in the benefit provider's database, and therefore the medical claim is returned as ineligible. In reality, in many of these situations, the patient/service/date/service provider information comprises eligible medical claims within the scope of the benefit plan, but there is a mistake or difference in the information on the medical claim and the information in the benefit provider's database, and so the medical claim is not considered eligible for reimbursement.

Additionally, while in many cases a medical claim 100 must be submitted within a certain time period after service is rendered, if the patient becomes eligible retroactively, but after the allowed time period for filing medical claims, a request can be made for payment for services that were rendered that would be covered by the benefit plan. Thus, it may be important to make inquiries as to eligibility status at frequent intervals to determine if a person is eligible while still within the time period during which a request for payment can be made.

Under certain new laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), which regulates the insurance benefit industry, service providers are authorized to access the benefit providers' databases 500, or to enable other parties to access the benefit providers' databases 500 on their behalf, to make inquiries as to patient eligibility status. In some instances, if certain specifications are met as to the software used and other requirements, the benefit provider must make the information in its database available for such inquiries without charge. Additionally, HIPAA mandates that benefit providers' databases should provide certain standard responses for cases where an eligibility query matches with a patient in a particular benefit provider's database, such that recognized patients are clearly identified even in cases where active eligibility covering the service dates does not exist. The purpose of this response is merely to alert the inquirer that the patient is recognized by the benefit provider's database. As an example, the software 10 described herein may be fully compliant with the new laws and regulations.

B. Operation

As shown in FIG. 1B, the software 10 may provide an analyzer 102 for converting and sorting a service provider's medical claims 100 and for generating a file of medical claims 200 in a form capable of being compared to the database of benefit providers 500 to find records 510 that match. The first step in the process encompassed by the software 10 is the generation of a file 200 containing the information from the service provider's unpaid medical claims 100 by the analyzer 102. Table 1 shows an example of the fields of a medical claim 100, although it should be appreciated that a variety of different numbers and arrangements of fields is possible. The exact fields 100 a to 100 n contained in each medical claim record 100 may vary, depending on what information is available in the service provider's records, and the information kept in the benefit provider's database 500.

TABLE 1 Field Example Claim data Patient ID No. 12345678 Patient Last Name Smith Patient First name John Patient Middle Name Q. Patient Date of Birth Jan. 1, 2000 Patient Address 123 Main St. Patient City Anytown Patient State Texas Patient Zip Code 12345 Patient Telephone No. (214) 867-5309 Benefit Plan Name Medicaid Benefit Plan No. Type B Insured's name Smith, John Q. Date of Service Jan. 28, 2004 Service Code ABC1234 Service Description Emergency Room Visit Charge Amount 250.00 Amount Paid 000.00 Balance Due 250.00

In another embodiment, the software 10 as described herein may sort the service provider's claims 100 by any of the fields 100 a to 100 n contained in each claim 100, such as, for example, a unique patient identifier and/or selected patient demographics (for example, name, social security number, date of birth, or the like). Such sorting of the medical claims may create one or more groupings of medical claims wherein each such grouping constitutes a cluster of patient claims. The software 10 may then create a composite medical claim 100 containing all of the relevant fields 100 a to 100 n within the cluster, and an analyzer 102 may then convert and sort a service provider's non-clustered medical claims 100 and composite medical claims 100 for generating a file of claims 200 in a form capable of being compared to the database of benefit providers 500 to find records 510 that match. Composite medical claims 100 may be used with a Date of Service description set to the prior seven days, though a person having ordinary skill in the art will understand that any date prior to the date of the query may be used in creating the composite medical claim 100.

Once the medical claim records 100 have been converted by the analyzer 102 to the proper format in file 200, the software 10 may employ one or more processing queries 300. These processing queries 300 utilize medical claim records 100 and/or composite medical claims 100 within file 200 as the basis of the collection of one or more queries 300′, 300″, and 300′″, and so on of the benefit provider's database 500. Each medical claim record 100 and/or composite medical claim 100 in the file 200 may be in the same format so the information therein can be compared to the records 510 in the benefit provider's database 500. The file 200 may be saved by the software 10 in a format that can be read and compared to the fields in the benefit provider's database 500.

The queries 300 contain instructions for comparing the fields 100 a to 100 n of each medical claim or composite medical claim 100 in the file 200 with the corresponding fields 510 a to 510 n of each record 510 in the benefit provider's database 500 of covered persons to determine if they contain matching information. Table 2 is an example of some of the types of queries 300 that can be executed using the software 10 described herein.

TABLE 2 Name Query Description MC Medicaid number only SSN Social Security number only MC SSN Medicaid & Social Security MC DOB Medicaid & Date of Birth MC FNLN Medicaid & First name, Last name SSN DOB Social Security & Date of Birth SSN FNLN Social Security & First name, Last name SSN LNFNINV SSN and First, Last Name switched SSN LNMN SSN & Last name, Middle name replacing First name DOB FNLN G F Date of Birth & First name, Last name & Gender (Female) DOB FNLN G M Date of Birth & First name, Last name & Gender (Male) SSN LN Social Security & Last name SSN LNFNMIa Social Security & full name, MI SSN LNFNMIb Social Security & last name, first name + MI SSN LNFNMIc Social Security & last name, first name, + “ “ + MI SSN LNFNMId Social Security & last name + MI, first name DOB FN4LN DOB & first name, 1^(st) 4 letters of last name SSN 4LN SSN & 1^(st) 4 letters of last name SSN LNFNMIe Social Security & last name + MI, first name DOB LNFNMIa Date of Birth & full name, MI DOB LNFN MIb Date of Birth & last name, first name + MI DOB LNFN MIc Date of Birth & last name, first name + “ “ + MI DOB LNFN MId Date of Birth & last name + MI, first name DOB LNFN MIe Date of Birth & last name + “ “ + MI, first name DOB LNFN Date of Birth & last name, first name DOB LNFNINV Date of Birth & last name, first name switched DOB LNMN Date of Birth & last name, middle name replacing first name DOB LNFNHA DOB & first name, 1^(st) half of hyphenated last name DOB LNFNHB DOB & first name, 2^(nd) half of hyphenated last name DOB LNFNHAB DOB & first name, hyphen/space removed from last name DOB LNFNHS DOB & first name, hyphen-> space in last name SSN LNFNHA SSN & first name, 1^(st) half of hyphenated last name SSN LNFNHB SSN & first name, 2^(nd) half of hyphenated last name SSN LNFNHAB SSN & first name, hyphen/space removed from last name SSN LNFNHS SSN & first name, hyphen -> space in last name

A query 300 can ask about a variety of information in various fields 510 a-n in the records 510 in the benefit provider's database 500. For example, a query 300′ could be as simple as checking to determine if the information in the patient identification number field 100 a of a service provider's medical claim record 100′ in the file 200 of claims matches the identification number field 510 a in any records 510 in the benefit provider's database 500. Or, a query 300″ could be more complex, and search for a variety of information matches, or partial matches, in multiple fields in the records 510 in the benefit provider's database 500. For example, the query 300″ could check for medical claims 100, or composite medical claims 100, and records 510 in which both the date of birth fields 100 b, 510 b in the file 200 and benefit provider's database 500 match, and also the first 4 letters of the last name fields 100 c, 510 c match. It can be appreciated that a very large variety of queries 300 can be configured and used. The queries 300 can be virtually unlimited, as long as the information to be queried is available in the service provider's records 100 and in the benefit provider's database 500.

The software 10 described herein may perform more queries 300, and more flexible queries, of the benefit provider's database 500, and may perform comparison and analysis to determine if there is a match between a medical claim 100, or composite medical claim 100, and a record in the benefit provider's database 500. It is this expanded scope and flexibility that results in a greater number of matched records than would otherwise be found.

If a query 300 matches a composite medical claim 100 to a record 510 in the benefit provider's database 500, then the software 10 described herein may add the underlying constituent medical claims 100 of the associated cluster to the file of remaining medical claims 200 to be compared to the benefit provider's database 500. Under the provisions of HIPAA, benefit providers' databases should provide certain affirmative standard responses for cases where an eligibility query matches with a patient in a particular benefit provider's database, and recognized patients are clearly identified even in cases where active eligibility covering the service dates does not exist. The software 10 may be capable of recognizing these affirmative standard responses, and when such responses are received, may add the underlying constituent medical claims 100 to the file of remaining medical claims 200 to be compared to the benefit provider's database 500. The clustering of medical claims 100 is useful because the same number of medical claims 100 may be compared with the benefit provider's database 500 using a smaller number of queries 300.

The software 10 described herein, in addition to finding matching records, because it does more queries 300, can also determine additional data about a medical claim 100, such as whether or not the claimed service is covered, the balance due on a medical claim 100, and even the amount of the balance due that is eligible for reimbursement. A surprising number of matches between service provider medical claims 100 and benefit provider databases 500 were found using embodiments of the software 10 described herein that were not found using other software. In one instance, a hospital, making just one set of queries 300, identified several million dollars in medical claims that were not previously found to be eligible for reimbursement.

Repeated execution of the queries 300 of the same benefit provider's database 500 at regular intervals, such as monthly or bi-weekly, continued to reveal medical claims 100 that were not eligible for reimbursement at the time the initial queries 300 were run, but subsequently became eligible for reimbursement. It can be appreciated that if these queries 300 were not subsequently run, the medical claims 100 found would not be reimbursed. Additionally, because there is typically a limited time period after a patient becomes eligible for benefits in which a medical claim 100 can be filed, it can be appreciated that if the queries 300 are not run at regular intervals, while matches could be found, they might be found too late for the service provider to seek reimbursement.

Additionally, it can be appreciated that identifying medical claims which would qualify for reimbursement under certain government medical programs would be important, even if reimbursement were not actually received, in order to help determine qualification for other government programs, and/or whether budget and funding estimates are accurate. For example, hospitals and other service providers that provide services to a large number of patients qualifying for Medicaid and/or Medicare could receive funding from another government fund for service providers who treat a disproportionate share of low-income patients. By using the results of the queries to identify qualifying patients, even if recovery cannot be made under the initial program, the treatment can be used for reporting and submitting requests for funding under secondary programs, such as the disproportionate share programs. For example, some patients who are treated who might qualify for reimbursement under state government managed programs may be from out of state, and therefore such a medical claim 100 may not be entitled to reimbursement. However, such unreimbursed medical claims may be used to qualify the service provider for reimbursement under secondary programs. The software 10 can be used to provide reports as to the patients treated, anticipated and projected funding, whether the service provider is treating more or less low-income patients than projected, and potential entitlement for future programs. This information is very useful to a service provider, as knowing this information can be used to project budgets, deficits and qualification for additional funding.

Typically, the first query 300′ might be to check for a person in the benefit provider's database 500 having a social security number/other unique identification number, and/or last name and first name that matches that of a patient for whom the hospital had provided services. Exactly which query 300 would be the first query 300′ would depend on how the benefit provider structures its database records.

Additionally, a query 300 can also be a series of sequential queries. For example, a query 300′ could be done to match the patient identification field 100 a in a medical claim 100 with the patient identification field 510 a for any matching record 510 from the benefit provider's database 500. If the patient ID number matches, then a second query 300″ can be made between these matching records found in response to query 300′ to determine if the date on which the service was provided falls within the dates of coverage provided by the benefit provider to that patient, and only if the answer to the second query 300″ is also positive will the record be set aside in the file 400 for further processing. Alternatively, the system could be configured so that if there is a match in the first electronic query 300′, the records could be flagged and set aside, and the second query 300″ could be done separately in a different query 300 or in or by a different system, or could even be done manually.

Note the software 10 can be configured so that all the queries 300 which are selected to be made could be run simultaneously or sequentially, or they could be grouped together and run sequentially. The purpose of different orders of queries or grouping of queries is to maximize efficiency of the software 10. The process in making such queries 300 of generally comparable records can also employ a variety of techniques, such as fuzzy and soundex searches, for example. It should be appreciated that the queries 300 selected, the order in which they are performed, and the groupings of queries can be adapted or modified, depending on results returned from the queries 300.

Once the queries 300 to be run have been selected and generated by the software 10, the benefit provider's database 500 is accessed, and the software 10 executes the first selected query 300′ thereon. If one or more matching records 510′ are found in the benefit provider's database 500 for a medical claim 100′, the medical claim 100′ is distinguished or flagged, removed from the file 200, and stored separately from the remainder of the medical claims 100 in the service provider's database 200 in a file 400, along with the information from matching records 510′ from database 500. The purpose of removing the matched medical claim 100′ from the file 200 is to streamline efficiency of the queries 300. Because one or more matches have already been made, there is no need to make additional queries 300 about this particular medical claim 100′. The query 300′ will then be performed for the next medical claims 100″ in the file 200 of service provider's medical claims, if any. If matches are found, then this medical claim 100″ and the matching records 510″ from the benefit provider's database 500 will also be stored in the file 400. If no match is found for medical claim 100″, the medical claim remains in the file 200. Query 300′ will be performed for each medical claim 100 in the file 200.

The software 10 may format composite medical claims 100′ in the EDI 270 batch file format recognized by HIPAA, for example. A query 300 may then be used to transmit the EDI 270 batch file, representing the composite medical claim 100′, to the benefit provider's database 500, which under the provisions of HIPAA should then return an EDI 271 batch file response stating that the patient was either found, or not found, in the benefit provider's database 500. If the benefit provider's database 500 recognizes the patient associated with composite medical claim 100′, then the composite medical claim 100′ is removed from the file 200, and each clustered medical claim 100 represented by the composite medical claim 100′ is added to file 200. The added clustered medical claims 100 may then be run against the benefit provider's database 500 using the selected queries 300 as described above.

If, after making the initial query 300′ of the benefit provider's database 500, there are still medical claims 100 in the service provider's file 200 that were not correlated with records 510 in the benefit provider's database 500, there are a variety of optional processes that could occur. In some embodiments, no additional actions could be taken, and the medical claims 100 remaining in the file 200 would remain in an ineligible status.

Alternatively, if there are additional queries 300″, 300′″, etc., that are in the selection of queries 300 to be made, the next query 300″ can be made of the benefit provider's database 500 to try and find additional matches with medical claims 100 in the service provider's medical claims file 200. Again, for each medical claim 100 in the file 200, query 300″ will be made of the benefit provider's database 500, and if any matches are found, that medical claim 100′″ is flagged, placed in the file 400 and removed from the file 200 of unmatched medical claims. The software 10 then continues to make the same query 300″ for each remaining medical claim 100 in the service provider's file 200. This cycle of querying/record flagging will continue until all medical claims 100 in the service provider's medical claims file 200 have been matched to at least a record 510 in the benefit provider's database 500, or until all queries specified have been made of the benefit provider's database 500 for all medical claims 100 in the service provider's medical claims file 200.

Once all the queries 300 of the benefit provider's database 500 have been run, the file 400 of all matched records is generated. In the file 400, each medical claim 100 is associated with the related matching record 510 from the benefit provider's database 500. For example, medical claim 100′, from the file 200 which was associated with a record 510′ from the benefit provider's database 500, will be grouped together in the file 400. The file 400 can be saved on a computer, or delivered via other methods, such as via the internet, as an attachment to an e-mail, as a facsimile, or as a physical document. A report 450 of contents of the file 400 can be generated and provided to the service provider so that the eligible medical claims can be submitted for payment by the service provider.

The report 450 can be delivered to the service provider in a variety of methods, depending on their preference, including delivery by e-mail, in paper form, or by internet or a variety of other forms. Reports 450 can include a variety of information such as the information from each medical claim 100 in the service provider's database for which any matching record 510 in the benefit provider's database 500 was found. FIGS. 2A, 2B, and 2C show samples of some of the many reports that can be generated using the software described herein.

As can be seen in the report in FIG. 2A, a listing is provided of medical claims for which a match was found in the benefit provider's database. Any information in the service provider's database that was incorrect or differed from that in the benefit provider's database may be shown in different print for assistance in easily identifying the problem so the medical claim can be corrected.

As can be seen, the report 450 shown in FIG. 2A is organized so that the service provider can easily review the information to determine those records having errors, and exactly what the errors are, so the medical claims can be corrected and resubmitted. In contrast, other existing software generated reports that simply listed names and identification numbers of patients for which a match was found in the benefit provider's database 500. No sorting of records was done as in the reports of the present disclosure, and no additional information was provided from the benefit provider's database 500, such as eligibility dates and billing deadlines, so additional manual analysis was required to determine if a medical claim could be submitted for payment. Additionally, because the other existing software did not do any multi-field comparisons or partial matches with analysis, records such as the first three shown in the sample report in FIG. 2A would not have been discovered at all.

A record such as the fourth record shown in the sample report in FIG. 2A, which would have appeared as eligible for reimbursement using other existing software, which only checked for a match of identifying information for the patient, would have resulted in a medical claim that was submitted being rejected, because the service type code was entered incorrectly. Using the software 10 described herein, which checks to see if the service rendered is eligible for reimbursement, would find the incorrect service code, which could be corrected before the medical claim 100 was submitted for reimbursement.

The fifth record shown in the sample report in FIG. 2A shows a medical claim 100 for which partial payment has been received, but for which there is still an outstanding balance. The software described herein has performed analysis to determine that the patient is covered by the benefit provider, and that the service is eligible for reimbursement. Therefore, the service provider can submit the medical claim 100 to seek to recover the outstanding balance. The report also shows the amount of the outstanding balance that is eligible for reimbursement. In this case, it is less than the full amount because the deductible for the benefit provider has not yet been met by this patient. This medical claim is also an example of a medical claim which has become eligible for benefits since the last time a report was run, and lists the date by which any claim must be made.

The last entry on the sample report of FIG. 2A shows a medical claim 100 that would have been qualified for reimbursement, had it been found and submitted in a timely manner. Such results would occur if the queries 300 described herein were not made on a regular basis.

FIG. 2B shows a pie chart break-out of an example of one instance in which the software 10 described herein was used showing the amount of medical claims eligible for reimbursement for a benefit provider, broken out by class of benefit provider, the number of medical claims for each class, and the amount of money for the medical claims for each class. Additional information from the service provider's and benefit provider's records that would be useful to the service provider in submitting the medical claim is also provided, such as the deadline, if any, by which the medical claim must be submitted.

FIG. 2C shows a report that provides information about medical claim eligibility verification for a variety of service providers, including the amounts identified for the medical claims, broken out for queries made on a regular basis. As can be seen, while the number for subsequent queries 300 typically decreases, it can be seen that additional eligible medical claims are identified when the software 10 is used to make subsequent queries 300.

It should be appreciated that a variety of different reports, report formats, and information can be used, depending on the needs of the service provider. The information in the reports 450 can be used for a variety of functions, such as to track errors, and possibly reduce similar future errors made when submitting medical claims. Additionally, the reports 450 can be used to monitor query results to determine the effectiveness of a particular query 300. If a particular query 300 does not ever produce any record matches, a decision could be made to not continue to make that query 300, or to enhance it in some way so as to increase the likelihood of obtaining a match.

Depending on the benefit provider's system, medical claims for which a match was found can be filed on-line, and/or a manual submission of medical claims for which payment is requested can be made.

The software 10 can be modified continually or periodically to ensure compliance with various local, state and/or federal laws, depending on where it is used. Additionally, because the world of medical service and benefit providers is rapidly and continuously changing and evolving, the software 10 described herein may be designed to be flexible and adapt to ongoing changes in the industry.

C. Examples

It is appreciated that some examples may be helpful in illustrating the features of the system and method described herein. If a service provider, such as a hospital, had a large number of medical claims 100 for services it had provided to patients (for example, an emergency room visit, a hospital stay, or the like), the software 10 could be used to inquire as to the status of the medical claims 100. The software 10 would first be used to generate a file 200 in the appropriate form that contained information for each medical claim 100. For purposes of this example, it is assumed that there are 90 (ninety) medical claims 100 in the file 200.

The software 10 may also be used to develop a series of one or more queries 300 that could be made of the benefit provider's database of members to find members of the benefit provider's plan for whom the service provider had rendered service, but has not yet been reimbursed. Again, only for purposes of this example, it is assumed that there are two queries to be made against the benefit provider database 500, sequentially, and a third query to be made for all records which were entered in file 400.

Typically, the first query 300′ might be to check for a person in the benefit provider's database 500 having a social security number/other unique identification number, and/or last name and first name that matches that of a patient for whom the hospital had provided services. Exactly which query 300 would be the first query 300′ would depend on how the benefit provider structures its database records.

Such an initial standard query is useful to patients eligible for reimbursement. In some situations, there is a delay in a patient being entered into a benefit provider's database, so if the medical claim is submitted to the benefit provider for payment before the patient has been added to the database, the medical claim 100 status will be returned as ineligible. Additionally, for some medical benefit programs, such as Medicaid and the Consolidated Omnibus Budget Reconciliation Act (COBRA), coverage can be retroactive. Similarly, in these situations, the patient may not appear in the database of persons qualifying for benefits under that plan when the patient is treated, or the database may indicate that the patient was not covered on the date the service was rendered. However, if the patient is added to the benefit provider's database subsequently, the medical claim will only be shown as “eligible” if the medical claim is resubmitted after the patient is in the benefit provider's database 500. In some instances, it has been found that several years can elapse before a medical claim 100 becomes eligible for reimbursement. However, in many cases, there is only a limited time allowed after a patient becomes eligible that medical claims 100 can be submitted to the benefit provider. Thus, queries 300 of the benefit provider's database 500 must be made on a regular basis so that eligible medical claims 100 can be identified in a timely manner, while the medical claims 100 can still be filed.

Another example of situations in which the patient may not appear in the benefit provider's database 500 when a medical claim is first submitted is for newborn babies. Such patients do not always have a unique ID number, such as a social security number, at birth. In some cases, there is even a delay in the patient being given a name, and the hospital records may simply refer to the child as “Baby Boy Smith.” Thus, the hospital may not have the proper information available to it to be able to generate a medical claim with information that matches the benefit provider's database 500. Even if the hospital had the correct name or identifying information, these patients are not added to the insurer's database until after the child is born, and there is typically a delay in such information getting entered into the database. Thus, the hospital could submit a medical claim 100 immediately after the child is born, and there could be no related record 510 in the benefit provider's database 500 at that time. Thus, these medical claims 100 are often not paid because they cannot be matched up with a patient in the benefit provider's database 500. Again, making eligibility inquiries of the benefit provider's database on a regular basis will reveal that the patient has been added to the database 500 and the medical claim 100 is eligible for reimbursement.

Another example of medical claims 100 that this query 300′ might find a match for would be an instance where the benefit provider matches records by patient name, rather than patient identification, and the benefit provider has a patient in its database 500 as John Smith, but the service provider submitted a medical claim for service provided to John Smithe. Because the benefit provider did not find John Smithe in its database, it originally rejected the medical claim as ineligible; however, because the patient IDs match, this query would make a match.

Once the queries 300 have been selected, the software 10 can be configured to run the selected queries 300 against the benefit provider's database 500 to find records that match any of the medical claims 100 in the file of the service provider's unpaid claims 200. Again, for purposes of this example, it is assumed that the first query 300′ is to find an exact match between the patient ID fields of any medical claim 100 in the file of the hospital's medical claims 200, and any patient record 510 in the benefit provider's database 500. For example, assume that when query 300′ has been run, and the data in each of the ninety medical claims 100 in the service provider's file 200 has been compared to the records 510 in the benefit provider's database 500, twenty of the medical claims 100 are found to have matching records 510 in the benefit provider's database, therefore being eligible for reimbursement. When a match is found for a medical claim 100′ in the benefit provider's database, that medical claim 100′ and the information from the matching record 510′ in the benefit provider's database 500 is placed in a file 400. Each medical claim 100 which has been matched to a record 510 from the benefit provider's database 500 is removed from the file 200 after query 300′ has been run and completed. Thus, after the first query 300′ has been run, only seventy medical claims 100 will remain in the file 200.

For purposes of this example, assume the second query 300″ is a query to find medical claims 100 in the seventy remaining medical claims in the file 200 for which the date of birth field is the same as the date of birth field in a record 510 in the benefit provider's database 500, the first name fields are the same, and the first four letters of the last name field are the same. This query would find patients for whom the patient ID was entered incorrectly, but the name and date of birth information was correct. Thus, if for patient Thomas Jones, his ID number was incorrectly entered in the service provider's medical claim as 12345679, but the actual ID number was 12345678, the first query 300′ would not find a matching record 510 in the benefit provider's database 500. However, the second query 300″ would find a matching record 510.

After the first query 300″ has been run, the second query 300″ is run for the remaining seventy medical claims 100 in the file 200. Assume this query results in another twenty medical claims 100 being matched with one or more records 510 in the benefit provider's database 500. Each of these twenty medical claims is also removed from file 200 and placed in file 400, leaving only fifty medical claims 100 in the file 200. It can be appreciated that with queries 300″ such as this, multiple matches could be found with persons having the same date of birth, first name, and last four digits of the last name, and therefore, multiple records 510 could be returned that potentially match a medical claim 100.

When all the queries 300 have been run, the software 10 will exit the query of the benefit provider's database 500, and a file 400 of all matched records is generated. In the case of this example, file 400 contains forty medical claims 100 for which one or more matches have been made in the benefit provider's database 500. The file 400 contains the information from each medical claim 100 for which a matching record 510 in the benefit provider's database 500 was found, and the information from the matching record(s) 510 in the benefit provider's database. A report 450 of contents of the file 400 can be generated and provided to the service provider so that the matched medical claims can be submitted to the benefit provider.

However, in the case of this example, the software runs a query 300′″ on all forty records in the file 400 to determine if the date by which a medical claim must be submitted for reimbursement is later than the present date. If not, that claim could be flagged in the file 400 as being a past deadline medical claim. Or, it could be a query that would check for additional matching fields between medical claims 100 that have generated more than one matching record 510 from the benefit provider's database 500. It can be appreciated that this query could have been made as part of the first or second queries 300′, 300″ of the benefit provider's database 500, or as a separate query 300 of the benefit provider's database 500. However, again, only for the purposes of this example, assume that it was found to be much more efficient to make this date query 300′″ after file 400 had been generated, rather than as a query to the benefit provider's database 500. Additionally, such information about medical claims qualifying for payment could be important for tracking whether a health care service provider qualifies for reimbursement from other programs, such as disproportionate share Medicaid or Medicare reimbursement funds, as discussed above. If this query was performed before the medical claim 100 was placed in the file 400, the medical claim 100 might not be placed in the file 400, and therefore it could be difficult to track this type of information when preparing reports to determine qualification for the additional programs. Alternatively, it can be appreciated that further inquiries such as this could be made manually upon review of the report 450 of matching files 400. Again, how such analysis is performed depends on the specific needs of a user.

If appropriate, additional analysis can be made of the service provider's medical claims 100 and any matching records 510 from the benefit provider's database 500 to determine if there are additional fields that match between the record in the benefit provider's database and the medical claim to ensure the patient is the same entity. For example, if multiple records 510 are returned that same date of birth, first name, and first 4 digits of the last name, additional analysis can be done to look for additional matches in other fields, or determine the probability that a specific record 510 matches a specific medical claim 100′.

In another embodiment, some of the medical claims 100 in the examples discussed above may be clustered together based on a unique patient identifier and/or patient demographics (name, social security number, date of birth, or the like) and a composite medical claim 100 may be created which contains this patient information. If a query 300 returns a matching record 510 from the benefit provider's database 500, or if the database 500 recognizes the patient as per HIPAA protocols, for example, then the software 10 may add the underlying clustered medical claims 100 to the file of remaining claims 200 and may then run every remaining medical claim 100 against the database 500 to determine whether a patient claim is eligible for reimbursement and can be submitted to the benefit provider for payment. In this way, the same number of medical claims 100 can be compared to the database 500 using fewer queries.

In one arrangement, queries 300 can be run of the benefit provider's database 500, with charges being incurred on a per query basis. In another arrangement, because the software 10 complies with the requirements of the new laws governing such queries 300, the queries 300 can be run without charge for the number of queries run, or the number of times queries are run. If the queries 300 are made by a third party on behalf of the service provider, payment to the third party can be made based on the number of medical claims 100 that are matched to database records 510, and for which payment is received by the service provider.

It is understood that the present invention can take many forms and embodiments. Accordingly, several variations may be made in the foregoing without departing from the spirit or the scope of the invention. Having thus described certain embodiments, it is noted that the embodiments disclosed are illustrative rather than limiting in nature and that a wide range of variations, modifications, changes, and substitutions are contemplated in the foregoing disclosure and, in some instances, some features of the present invention may be employed without a corresponding use of the other features. Many such variations and modifications may be considered obvious and desirable by those skilled in the art based upon a review of the foregoing description of illustrative embodiments. Accordingly, it is appropriate that the appended claims be construed broadly and in a manner consistent with the scope of the invention. 

1. A computer readable medium for determining eligibility of medical claims for reimbursement, said computer readable medium comprising instructions for: sorting a set of medical claims relating to a plurality of patients according to one or more selected criteria to form one or more clusters, wherein each of said one or more clusters comprises a plurality of constituent medical claims; for each of said clusters, creating a composite medical claim representative of each respective one of said clusters; querying a benefit provider's database based on each of said composite medical claims to determine whether a patient is recognized; and for each composite medical claim for which a patient is recognized, querying said database based on each one of the respective plurality of constituent medical claims to determine whether said database contains one or more matching records that correspond at least in part to one or more fields of information in any of said respective plurality of constituent medical claims.
 2. The computer readable medium of claim 1 further comprising instructions for identifying at least one of said respective plurality of constituent medical claims for which there is a matching record in said database that corresponds at least in part to one or more fields of information in said at least one of said respective plurality of constituent medical claims.
 3. The computer readable medium of claim 2 further comprising instructions for submitting said at least one of said respective plurality of constituent medical claims to said benefit provider for reimbursement.
 4. A method of determining eligibility of medical claims for reimbursement, said method comprising: sorting a plurality of medical claims relating to a plurality of patients according to one or more selected criteria to form one or more clusters, wherein each of said one or more clusters comprises a plurality of constituent medical claims; for each of said clusters, creating a composite medical claim representative of each respective one of said clusters; querying a benefit provider's database based on each of said composite medical claims to determine whether a patient is recognized; and for each composite medical claim for which a patient is recognized, querying said database based on each one of the respective plurality of constituent medical claims to determine whether said database contains one or more matching records that correspond at least in part to one or more fields of information in any of said respective plurality of constituent medical claims.
 5. The method of claim 4 further comprising identifying at least one of said respective plurality of constituent medical claims for which there is a matching record in said database that corresponds at least in part to one or more fields of information in said at least one of said respective plurality of constituent medical claims.
 6. The method of claim 5 further comprising submitting said at least one of said respective plurality of constituent medical claims to said benefit provider for reimbursement. 